Background

 

 

Definition

 

Full thickness tear (FTT) - complete tendon tear / avulsion from foot print

Partial thickness tear (PTT) - partial thickness tendon tears / bursal or articular sided

 

Epidemiology

 

95% atraumatic / degenerative

 

Incidence

 

Teunis et al JSES 2014

- systematic review of incidence RC pathology

- 30 - 49: 13%

- 50 - 59: 19%

- 60 - 69: 30%

- 70 - 79: 41%

- > 80:     62%

 

Bilateral

 

Yamaguchi et al JBJS Am 2006

- patients > 65 with painful full thickness cuff tear

- 50% chance of unilateral asymptomatic cuff tear

 

Natural history of rotator cuff tears

 

Keener et al JBJS Am 2015

- 118 full thickness rotator cuff tears

- 61% enlarged over a 3 year period

 

Garcia et al JBJS Open 2024

- systematic review of progression

- partial tears: 27% at 2 years

- full thickness tears: 55% at 2 years

 

Anatomy

 

Blood Supply

 

Proximal from muscle belly / Distal from bone

Vessels more abundant on bursal side than articular side

 

Foot print

 

Supraspinatus: mean 13 mm anterior to posterior

Infraspinatus: 32 mm curving superiorly

 

Pathology

 

Jeong et al AJSM 2018

- MRI of 245 patients with RC tears

- mean size 11 x 11 mm

- most located 10 mm posterior to long head of biceps

 

History

 

Pain and weakness

 

Examination

 

 Muscle wasting of supraspinatus and infraspinatus

 

 

Rotator cuff strength

Supraspinatus	Infraspinatus
Patient's arm forward flexed 90° Thumb down	Resist external rotation

 

Subscapularis
Gerber lift-off test - internally rotate hand to back pocket - can lift hand away - need sufficient internal rotation to perform test	Belly press test - fists on belly - elbows forward to eliminate deltoid - resist force lifting fists away from belly

 

Pseudoparalysis / Shoulder hiking

 

 

Xray

 

Look for: acromial morphology / high riding humeral head / rotator cuff arthropathy

 

Acromial spur / superior migration humeral head / rotator cuff arthropathy

 

Ultrasound

 

Normal

 

 

Farooqi et al OJSM 2021

- systematic review of US rotator cuff tears

- US more accurate for supraspinatus and biceps than subscapularis

- US more accurate for full thickness tears than partial thickness tears

 

MRI

 

Look for

- supraspinatus / infraspinatus / subscapularis / long head of biceps pathology

- partial verus full thickness

- size of tear in coronal and sagittal planes

- retraction

- atrophy / fatty infiltration 

 

Full thickness rotator cuff tears

 

Partial bursal sided tear                               Partial articular sided tears

 

Subscapularis tears

 

Classification

 

Size	Tendons	Topography	Patte Retraction on coronal MRI
Small       < 1 cm Moderate  1-3 cm Large       3-5 cm Massive    > 5 cm	Supraspinatus Infraspinatus Subscapularis	Superior - supraspinatus Anterosuperior - supraspinatus / subscapularis Posterosuperior - supraspinatus / infraspinatus	I: To footprint II: Articular surface / midhumeral head III: To or beyond glenoid

 

Measure tear in the coronal and sagittal plane

 

Small full thickness rotator cuff tear of supraspinatus - retracted to footprint

 

Large full thickness tear of supraspinatus and infraspinatus tendon - retracted to midhumeral head

 

Massive rotator cuff tear of the supraspinatus and infraspinatus tendon - retracted to glenoid

 

Goutallier classification

 

Amount of fatty degeneration in rotator cuff muscle belly on a T1 sagittal MRI

 

Tsuchiya et al JSES 2023

- systematic review of Goutallier grade and retear rates

- retear rates after surgical repair increase as the Goutallier stage increases

 

Stage 0: normal muscle

 

Stage 1	Stage 2
Some fatty streaks MRI shows some fatty streaks in supraspinatus	More muscle than fat MRI shows grade 2 in supraspinatus

Stage 3	Stage 4
Equal fat and muscle MRI demonstrates grade 3 supraspinatus and infraspinatus	More fat than muscle MRI demonstrates grade 4 infraspinatus

 

Supraspinatus atrophy

 

Tangent sign

- sagittal MRI

- line connecting superior coracoid and superior border scapular spine

- if supraspinatus muscle is below line, there is significant atrophy

- positive tangent sign / significant atrophy associated with larger tears / irrepairable tears

 

Negative tangent / no atrophy                   Positive tangent / significant supraspinatus atrophy

 

Arthroscopy

 

Tear patterns of supraspinatus and infraspinatus

Crescent shaped	U shaped	L Shaped
Small to medium tears Repair to footprint	Large tears Need margin convergence then repair to footprint	Antero-superior or postero-superior tears Need to mobilize cuff anterior or posterior

 

Crescent, U shaped and massive rotator cuff tears

 

Non operative management

 

Physiotherapy

 

Kuhn et al JBJS 2024

- prospective cohort study of 450 patients with symptomatic full-thickness atraumatic cuff tears

- 6-12 weeks of physiotherapy

- only 27% elected for surgery (most in first 6 months)

- low expectation of physiotherapy, workers comp., and high functional demand predicted later surgery

 

Injections

 

Jiang et al J Orthop Surg Res 2023

- systematic review of cortisone v HA v PRP for rotator cuff tears

- 12 RCTs and 1000 patients

- short term pain relief with HA

- longer term pain relief and functional improvement with PRP

 

Operative versus nonoperative management

 

Longo et al BMC MSK 2021

- meta-analysis of 6 RCT comparing operative v nonoperative management

- no difference in functional scores at 12 months

- better VAS with surgery at 12 months

 

Kukkonen et al JSES 2021

- 5 year follow up of RCT

- 150 patients with 1 cm tear > 55

- no difference in functional outcome